Catalytic Health

6 Volume 3, Issue 1, May, 2023 W H E N P R U R I T U S I S N O T A L L E R G Y: A P P R O P R I AT E S I G N S O F LY M P H O M A A N D O T H E R M A L I G N A N C I E S F O R T H E C O M M U N I T Y A L L E R G I S T Case A 29-year-old woman presented in 2020 with a several-month history of intense pruritus with neck and truncal rash (Figure 1A). During the spring, she reported recurrently to health care with intermittent respiratory symptoms, and persistent fever and sweats. X-ray imaging suggested left sided pneumonia with an effusion, for which she received several courses of antibiotics and eventually underwent thoracentesis in June 2020. Concurrently, she noted nodularity in the skin of her upper back and sternum. Past medical history included scoliosis and anemia, initially thought to be related to iron deficiency, though later testing suggested anemia due to inflammation. She had previously developed cutaneous patches, but without a formal dermatologic diagnosis. Of note, she had a family history of psoriasis. CT imaging in July 2020 demonstrated diffuse opacities within her right lung with partial collapse of her right upper lobe, bilateral pleural effusions, and extensive soft tissue in the mediastinum encasing various venous structures, the pericardium and heart with small pericardial effusion. Mediastinal mass core biopsy demonstrated nodular sclerosing Hodgkin lymphoma. The patient was treated with ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) chemotherapy for six cycles and achieved a complete remission. With treatment, her pruritus and rash resolved within 1-2 months; however, she subsequently developed drug-induced flagellate dermatitis 1 , which has slowly faded since treatment completion (Figure 1B). She remains in remission at most recent follow up. Pruritus Pruritus is a common symptom, with 8%-22% of individuals experiencing chronic pruritus defined as an itch lasting longer than six weeks 2-4 . In a prospective study of patients presenting to an outpatient dermatology clinic with chronic pruritus, 22% were diagnosed with an underlying systemic etiology. 5 With some exceptions, the majority of systemic causes are associated with normal appearing skin. Systemic causes of pruritus are extensive, including renal, hepatic, endocrine, hematologic, and iatrogenic (Table 1). Malignancy is an uncommon etiology of pruritus. 6,7 In a population-based cohort of 8,744 patients with chronic pruritus, compared to age- and sex- matched controls, patients with chronic pruritus had higher rates of alcohol use, smoking, higher Figure 1A. Demonstration of neck and truncal rash prior to diagnosis; photo courtesy of Amaris Balitsky, MD and Gwynivere Davies, MD Figure 1B. Hyperpigmentation from bleomycin-induced flagellate dermatitis that developed during treatment with ABVD; photo courtesy of Amaris Balitsky, MD and Gwynivere Davies, MD

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